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Abstract

This comparative case study describes the organization, delivery, and content of care of three maternity care models serving low-income women at risk of poor birth outcomes in Wards 5, 6, and 7 in Washington D.C. The first model, a birth center, provides prenatal care, birth services, postpartum follow-up, and infant and child health care. The second is a safety net clinic, which provides a variety of primary health care services, as well as prenatal care services. A not-for-profit teaching and research hospital represents a third option in which prenatal and postnatal care is provided through an on-site obstetric clinic.

Introduction

The District of Columbia is home to some of the worst pregnancy outcomes in the country, including very high rates of infant mortality, preterm birth, low birth weight, and high cesarean section rates (Martin et al, 2006; Mathews et al, 2007). African American women and their babies in particular exhibit worse birth outcomes than white or Latina women in the District (Martin et al, 2006; Mathews et al, 2007). Residents in wards 5, 6 and 7 in the District (situated in the North and East of the city) are predominately African American and low-income. This comparative case study aims to understand how obstetric care provided under three models varies and how it might be improved to better serve this population.

The first of the three models is a city birth center that provides prenatal care, birth services, postpartum follow-up, and infant and child health care. Certified nurse-midwives (CNMs) are the primary maternity care providers. Women meeting established criteria (see Appendix A) can choose to either give birth at the birth center or at a nearby teaching hospital, attended by a birth center CNM regardless of birth location. Women in Wards 5, 6, and 7 might also receive maternity care through one of D.C.’s ten Federally Qualified Health Care Centers (FQHCs). This study focuses on one of these safety net clinics, which provides a variety of primary health care services, as well as prenatal care services. The care model at the safety net clinic uses CNMs and obstetricians to provide prenatal and postnatal care. The safety net clinic collaborates with the teaching hospital to provide easy access to the hospital’s obstetric and gynecological services. Under this arrangement, hospital obstetricians provide prenatal care at the FQHC a few days a week. Most women receiving their prenatal care at the safety net clinic give birth at the teaching hospital. The not-for-profit teaching and research hospital represents a third and different option for women in the city. The hospital provides prenatal and postnatal care through an on-site obstetric clinic where women receive care from either residents or a nurse practitioner. The hospital has a maternity wing for births where residents are the main care providers supervised by attending physicians, and supported by nurses.

This report presents a descriptive overview of each model of maternity care in a case study format, including how maternity services are delivered to women in Wards 5, 6, and 7 under each model, what composes the content of the care, and how the care is perceived by women and providers. A forth-coming paper will provide a comparative analysis of each model which will also discuss the implication of models of maternity care on cost-effectiveness and service delivery efficiency (also see Appendix B for a matrix comparing the key characteristics of care across the three study sites). We hope the results will inform a future impact study of the effects of different models of birth care on birth outcomes, and cost-effectiveness.

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